Shah NL, Northup PG, Caldwell SH

Language: English
References: 15
Page: 686-690
PDF size: 83.23 Kb.

ABSTRACT

Background. The relative incidence of bleeding and thrombotic events and the use of blood products in hospitalized cirrhosis patients have not been widely reported. We aimed to estimate the magnitude of bleeding events and venous thrombosis in consecutive hospitalized cirrhotic patients over a finite time period and to examine the amount and indications for blood product use in cirrhosis patients admitted to a tertiary care center. Results. Among patients admitted with decompensated liver disease, 34 (40%) suffered bleeding events (about one-half non-variceal) and 6 patients (7%) suffered deep venous thrombosis. In the blood product survey, 168 patients were transfused with plasma or platelets during the survey intervals. Liver disease patients accounted for 7.7% of the total but disproportionately consumed 32.4% (46 of 142) of the units of plasma mostly administered as prophylaxis. In contrast, cirrhosis patients received only 7 of the 53 units of platelets transfused (13.2%) during the survey intervals. Conclusions. Coagulation issues constitute a common problem in patients with liver disease. Recent advances in laboratory testing have shown that stable cirrhosis patients are relatively hypercoagulable. The result of this prospective survey among decompensated (unstable) cirrhosis patients shows that, while DVT is not uncommon, bleeding (non-variceal in one half) remains the dominant clinical problem. This situation likely sustains the common practice of plasma infusion in these patients although its use is of unproven and questionable benefit. Better clinical tools are needed to refine clinical practice in this setting.

REFERENCES

1. Kim WR, Brown RS Jr, Terrault NA, El-Serag H. Burden of liver disease in the United States: summary of a workshop. Hepatology 2002; 36: 227-42.

2. Caldwell SH, Hoffman M, Lisman T, Macik BG, Northup PG, Reddy KR, et al. Coagulation disorders and hemostasis in liver disease: pathophysiology and critical assessment of current management. Hepatology 2006; 44: 1039-46.

3. Mannucci PM. Abnormal hemostasis tests and bleeding in chronic liver disease: are they related? No. J Thromb Haemost 2006; 4: 721-3.

4. Tripodi A, Caldwell SH, Hoffman M, Trotter JF, Sanyal AJ. Review article: the prothrombin time test as a measure of bleeding risk and prognosis in liver disease. Aliment Pharmacol Ther 2007; 26: 141-8.

5. Tripodi A, Mannucci PM. Abnormalities of hemostasis in chronic liver disease: reappraisal of their clinical significance and need for clinical and laboratory research. J Hepatol 2007; 46: 727-33.

6. Northup PG. Hypercoagulation in liver disease. Clin Liver Dis 2009; 13: 109-16.

7. Lisman T, Bongers TN, Adelmeijer J, Janssen HLA, De Maat MPM, De Groot PG, Leebeek FWG. Elevated levels of von Willebrand Factor in cirrhosis support platelet adhesion despite reduced functional capacity. Hepatology 2006; 44: 53-61.

8. Northup PG, McMahon MM, Ruhl AP, Altschuler SE, Volk- Bednarz A, Caldwell SH, Berg CL. Coagulopathy does not fully protect hospitalized cirrhosis patients from peripheral venous thromboembolism. Am J Gastroenterol 2006; 101: 1524-8.

9. Dabbagh O, Oza A, Prakash S, Sunna R, Saettele TM. Coagulopathy does not protect against venous thromboembolism in hospitalized patients with chronic liver disease. Chest 2010; 137: 1145-9.

10. Sogaard KK, Horvath-Puho E, Gronbaek H, Jepsen P, Vilstrup H, Sorensen HT. Risk of venous thromboembolism in patients with liver disease: a nationwide population-based case-control study. Am J Gastroenterol 2009; 104: 96-101.

11. Tripodi A, Primignani M, Chantarangkul V, Dell’Era A, Clerici M, De Franchis R, et al. An imbalance of pro- vs anti-coagulation factors in plasma from patients with cirrhosis. Gastroenterology 2009; 137: 2105-11.

12. Trotter JF, Olson J, Lefkowitz J, Smith AD, Arjal R, Kenison J. Changes in international normalized ratio (INR) and model for endstage liver disease (MELD) based on selection of clinical laboratory. Am J Transplant 2007; 7: 1624-8.

13. Lisman T, van Leeuwen Y, Adelmeijer J, Pereboom IT, Haagsma EB, van den Berg AP, Porte RJ. Interlaboratory variability in assessment of the model of end-stage liver disease score. Liver Int 2008; 28: 1344-51.

14. Alkozai EM, Lisman T, Porte RJ. Bleeding in liver surgery: prevention and treatment. Clin Liver Dis 2009; 13: 145-54.

15. Lisman T, Caldwell SH, Burroughs AK, Northup PG, Senzolo M, Stravitz RT, Tripodi A. et al. Hemostasis and thrombosis in patients with liver disease: the ups and downs. J Hepatol 2010; 53: 362-71.